Airway complications on the general medical unit after prolonged ICU admission

Airway complications on the general medical unit after prolonged ICU admission Palash Kar Discipline of Acute Care Medicine, University of Adelaide Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

Three facts that may shock you: Movie

Movie Three facts that may shock you: That was not filmed at the Royal Adelaide Hospital ICU

Movie Three facts that may shock you: That was not filmed at the Royal Adelaide Hospital ICU Whiskey out of a flask is not used to sterilise equipment

Movie Three facts that may shock you: That was not filmed at the Royal Adelaide Hospital ICU Whiskey out of a flask is not used to sterilise equipment Biros are not used as tracheostomy tubes

Introduction Advances in intensive care increased patient survival in those who would have otherwise succumbed Those requiring prolonged mechanical ventilation tracheostomy

What is a tracheostomy?

What is a tracheostomy? An airway that is inserted (subglottically) through neck tissues directly into the trachea Waugh et al. Ross & Wilson Anatomy and Physiology in Health and Illness, 11 th edition (2010)

Types Emergency (Crico-thyroid) Percutaneous (Needle) Surgical Elective (Tracheal rings) Percutaneous Surgical Boundless. Anatomy & Physiology (2013)

Tracheostomy tubes Outer tube Inner tube fits snugly into outer tube Flange flat plastic plate allows the tube to be secured Connector Obturator Klaus PD. https://commons.wikimedia.org/wiki/file:tracheostomy_tube.jpg (2008)

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

Background 3600 BC Seen on Egyptian tablets 2000 BC Sacred hindu texts ( Rigveda ) 400 BC Hippocrates condemned the practice unacceptable risk of carotid artery damage Sitting et al. AARC Times (2001) Ferlito et al. Acta Otolaryngolica (2003)

Antonio Musa Brassavola 1546 Performed the first documented successful tracheostomy Patient with laryngeal abscess Goodall EW. British Journal of Children s Diseases (1934)

Scultetus J. Armamentarium chirurgicum bipartitum, (1666)

Friedrich Trendelenburg 1869 First proposed the use of a cuffed tracheostomy tube Lomholt N. Acta Anaesthesiologica Scandanavia (1967)

Chevalier Jackson 1909 Described the current used surgical technique Emphasised post operative care Carol et al. Journal of the Irish Colleges of Physicians and Surgeons (2001)

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

Uses Mechanical ventilation is expected to be prolonged

Uses Mechanical ventilation is expected to be prolonged Comfort/reduced sedation Decreases work of breathing Weaning off ventilator Communication Nursing care (mouth care and mobility) Ease of replacement of tracheal tube Facilitate transfer to the ward

Disadvantages Needs a surgical procedure Inherent risks of invasive procedure

Disadvantages Needs a surgical procedure Inherent risks of invasive procedure Early Bleeding, pneumothorax, surgical emphysema, malposition, damage to local structures, death Delayed Infection, obstruction, ulceration, dysphagia, decanulation issues Late Stenosis, granuloma, persistent sinus, tracheomalacia

Disadvantages Needs a surgical procedure Inherent risks of invasive procedure Issues with speech/swallowing Looks Living with tracheostomy Early Bleeding, pneumothorax, surgical emphysema, malposition, damage to local structures, death Delayed Infection, obstruction, ulceration, dysphagia, decanulation issues Late Stenosis, granuloma, persistent sinus, tracheomalacia

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

Techniques Emergency Percutaneous (Needle) Surgical Elective Percutaneous Surgical

Surgical Emergency

Emergency Surgical Percutaneous (Needle)

Emergency Surgical Percutaneous (Needle) Oxygenation Transtracheal Jet Ventilation Patel R. Chest (1999)

Elective Surgical surgical dissection down to trachea with insertion of tracheostomy tube for ventilation

Elective Surgical surgical dissection down to trachea with insertion of tracheostomy tube for ventilation Percutaneous different techniques to insert a tracheostomy Gradual dilatation Forceps dilatation

Surgical vs Percutaneous Surgical: Under direct vision Better for difficult cases Avoid aberrant vessels Percutaneous: Less bleeding Quicker and cheaper Can be done in the ICU Can be performed sooner

Tracheostomy

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

Issues on the ward Respiratory distress Blocked/displaced tube Bleeding

Respiratory distress

Respiratory distress Tracheostomy tube Blocked/displaced?

Respiratory distress Tracheostomy tube Blocked/displaced? Needs removal or replacement Can you pass a catheter

Respiratory distress Tracheostomy tube Blocked/displaced? Needs removal or replacement Can you pass a catheter Cuffed/uncuffed

Respiratory distress Tracheostomy tube Blocked/displaced? Needs removal or replacement Can you pass a catheter Cuffed/uncuffed Need a cuff for positive pressure ventilation Look for a pilot balloon

Cuffed/uncuffed tube https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy-guidelines/communication/ (2015)

Respiratory distress Tracheostomy tube Inner tube to be inserted? ensure it fits When was tracheostomy performed? Safe to reinsert tracheostomy tube if >7 days Intubate? Laryngectomy or supraglottic pathology intubation not possible

Approach ABCs Breathing at mouth/tracheostomy CPR if indicated High flow oxygen to mouth/nose/stoma Check if tracheostomy tube is patent Look for other causes

Blocked/displaced tube Remove tube Oxygenation/ventilation Mouth Stoma Consider Endotracheal intubation Intubation of stoma airway adjuncts + small tube (size 6.0)

Issues on the ward Respiratory distress Blocked/displaced tube Bleeding

Bleeding

Bleeding Early (peri-operative) bleeding More common Usually benign Late bleeding Potentially life threatening

Causes Specific to tracheostomy Early (peri-operative) bleeding Suction/Manipulation Late bleeding Granulation tissue Infection Tracheo-innominate fistula

Tracheo-innominate fistula

Tracheo-innominate fistula Pressure necrosis of anterior tracheal wall from tube causing erosion of trachea and innominate artery (brachiocephalic trunk) Incidence <1% Survival 15% Mortality is 100% without surgical intervention 75% develop within 3 weeks after tracheostomy

Antomy Brachiocephalic trunk First branch of the aorta Traverses trachea at 8-10 th ring Anatomical variants exist Grant et al. British Journal of Anaesthesia (2006)

Contributing factors

a. Trachea erosion into BCT b. Abnormally high BCT c. Low positioned tracheostomy Jones et al. Annuls of Surgery (1976)

Contributing factors Cuff overinflation Local infection Excessive manipulation of tracheostomy Long term ventilation Radiation therapy Steroids

Diagnosis Early diagnosis is KEY! Warning signs Sentinel bleed (small bleed in preceding hours) Pulsating tracheostomy tube Imaging scope, CT angiogram, angiogram

Initial management Cuff overinflation Oral ETT distal to site Digital compression Pre tracheal space Trachea against sternum Take to theatre Jones et al. Annuls of Surgery (1976)

Initial management Cuff overinflation Oral ETT distal to site Digital compression Pre tracheal space Trachea against sternum Take to theatre Ridley et al. The Journal of Laryngology & Otology (2006) Jones et al. Annuls of Surgery (1976)

Approach ABCs and call for help Clear airway clots may need suctioning Consider finger pressure/cuff hyperinflation Correct coagulopathy and replace blood products Urgent surgical referral Consider palliation situation may be fatal If it settles investigate other causes

Issues on the ward Respiratory distress Blocked/displaced tube Bleeding

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

Decanulation

Decanulation Weaning Direct removal Routine downsizing Changing to a cuffless tube Capping/corking tube Specific to clinician and institution

Decanulation Mechanical ventilation is no longer required Adequate cough Secretions are minimal ability to clear Upper airway obstruction is absent Co-operative patient

Post decanulation Tracheal stenosis usually between stoma and cords Symptomatic or asymptomatic 3-12% require intervention Worsening dyspnoa, stridor, etc Tracheomalacia weakened tracheal wall airway collapse Symptoms range from dyspnoea to failure to wean Epstien S. Respiratory Care (2005)

Post decanulation Tracheo-oesophageal fistula Dyspnoea, pneumonia, recurrent aspiration, gastric distension Tracheo-innominate fistula Aspiration Epstien S. Respiratory Care (2005)

Tracheostomies Introduction Background Uses and disadvantages Techniques Issues on the ward Decanulation

In the news

In the news Dr Royce Johnson

In the news

Pauline Larwood In the news

Key points Tracheostomy is a subglottic airway inserted through neck directly into the trachea Two broad groups (emergency and elective) ward patients will have elective airways Two main techniques for each type percutaneous and surgical

Key points Respiratory distress and bleeding - main issues on the ward ABCs recognise issues specific to tracheostomy tubes (occlusion, fistulas, etc) and treat if possible It takes 7 days for a tract to form Cuffed or uncuffed tubes Watch out for SENTINEL BLEEDS Recognise late post tracheostomy complications

The End

The End With thanks to: A/Prof Adam Deane, Prof Michael Horowitz, Prof Karen Jones Dr Liza Phillips, Dr Yasmine Ali Abdelhamid and the team at ICU Research Palash Kar p_kar@hotmail.com Palash.Kar@adelaide.edu.au